|Year : 2014 | Volume
| Issue : 2 | Page : 81-82
Why patients in pain cannot get "God's own medicine?"
Section Editor, JPP, India
|Date of Web Publication||7-Apr-2014|
Department of Pharmacology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Batmanabane G. Why patients in pain cannot get "God's own medicine?". J Pharmacol Pharmacother 2014;5:81-2
"Among the remedies which it has pleased almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium."
-Sir Thomas Sydenham (1680)
Opium is a drug, which has been used for centuries before and after Christ. Feted as "God's own medicine" by Sir William Osler, it is perhaps the only drug over which two wars were fought. The fact that it is still used today for many of its original indications is a tribute to its versatility. Morphine hit the news on the internet recently, when a group of graduate students from the University of British Columbia, Vancouver made and aired a documentary film titled "freedom from pain," which described its unavailability for people in pain in countries such as India and Ukraine.  Freedom from living in pain should be a fundamental right and healthcare systems must ensure that adequate pain medications are made available to those in constant severe pain from cancer, HIV and other illnesses. Steve Jobs, the founder of Apple, received opioids for his pain when he suffered from the terminal stages of pancreatic cancer. It is thought that the respiratory arrest from which he died was brought on by the opioids.  The fact that the drug of choice for severe deep-seated chronic pain is morphine seems a double edged sword of sorts.
Opium is legally produced in India for medicinal uses in Madhya Pradesh, Uttar Pradesh and Rajasthan. India is the only country in the world that legally produces opium gum.  The opium gum produced by the cultivators is procured by the government. This is then dried and exported or the alkaloids extracted and sold to pharmaceutical companies. Recently, the government relaxed the rules to permit pharmaceutical companies to extract alkaloids from opium. In 2010-2011, nearly 1,014 tons of opium was produced in India,  an amount adequate to satisfy the country's need of morphine. Unfortunately, most of this was exported, leading to shortage of morphine in the country. Under the narcotic drugs and psychotropic substances (NDPS) Act, 1985, all narcotic drugs are strictly controlled, which includes the manufacture, transportation, storage, and dispensing. Any hospital wanting to dispense morphine to patients has to apply for a permit stating the exact quantities that will be procured and justifying the quantities requested. Next, they need to get a permit for storage and for the transport. Even after the drug is received, it has to be kept under lock and key with two people signing a register detailing the use. Monthly utilization certificates have to be filed. With all this paperwork and legal formalities, it is small wonder that any hospital would want to continue to dispense morphine to their patients. What the legal minds who drafted the NDPS did not realize was that the draconian law would deter pharmaceutical companies from manufacturing these drugs in India. Morphine is not under patent protection and therefore, the cost of the drug is low. Companies stand to make very little profit out of a drug which requires very stringent, time-consuming and complicated procedural processes. As this is not an economically sustainable proposition for the pharmaceutical companies there is very little enthusiasm to market this drug in India. Those who are forgotten and get left out of the equation are the most important stakeholders in this story-the patients who desperately need morphine for their pain. Prescription and use of morphine in India is very very low compared with the developed countries, which do not produce opium. 
Studies have shown that pain is inadequately treated even in developed countries. There is a reluctance among doctors to use morphine effectively in the management of cancer pain.  The argument that morphine may produce addiction in patients with pain has long been overturned. However, it is not easy to change the mindset of doctors. Oral morphine is the drug of choice for most patients with chronic cancer pain. Pharmacologically, oral morphine cannot produce the "high" that intravenous morphine produces as the euphoric effects of opiates occur in the dopaminergic pathway from the ventral tegmental area to the nucleus accumbens, where opiates increase synaptic levels of dopamine.  For the "high" to occur the rate of change in dopamine should be fast as seen with intravenous administration, when opiates block gamma-aminobutyric acid inhibition and produce a burst of nucleus accumbens activity. Oral and transdermal routes of administration tend to increase the blood levels of opiates slowly and some of the analgesic and respiratory depressant effects are due to stimulation of opiate receptors located in other areas of the brain such as the locus coeruleus.  However, this rationale is neither taught nor followed in practice leading to inadequate use of opioids when necessary.
Patients in palliative care are often turned away with simple analgesics when morphine should be prescribed. ,, Their agony is unheard as most of them are poor and do not have access to good palliative care. Even if morphine were available, under the NDPS only 90 tablets can be issued to a patient at one time. A patient requires to take the tablets six times a day for adequate relief of pain. Hence patients get tablets which lasts for 2 weeks. If tablets of lower strength are available, they have to come more often. Most of them are so ill that they cannot easily make the trip to the hospital where they can receive the drugs. Though oral morphine is listed in the National List of Essential Medicines 2011, the tablets are not available in primary health centers, which would be the nearest place where they can go to receive them. This issue led to a public interest litigation in the supreme court which ordered that morphine should be made available to patients.  Except for Kerala, where efforts by individuals interested in palliative care have made a difference, the problem remains very much the same in the rest of the country. , The rich will be able to afford and obtain the more expensive narcotic drugs while the poor will continue to die in pain. In countries such as the United States of America, United Kingdom, Australia, and Canada, treatment of cancer pain has taken a new dimension, with patients receiving personalized pain management. Sadly though, the opium grown in our country is used to alleviate the pain of people living in other developed countries, but not in our own.
Even though approximately, 27 million people are suffering in pain around the world, more than 150 countries cannot access morphine for patients needing palliative care.  Besides, most doctors are unwilling to become involved in treating pain in palliative care. There is a need to bring about curricular reform at the undergraduate and postgraduate levels, conduct professional development programs to change this mindset and educate patients to demand their right to be free from pain. Unfortunately, none of these will be effective unless the government realizes its folly with regard to the NDPS and is able to change the regulations to differentiate between the use of opioids for treatment of pain and the abuse of opioids. Furthermore, the Department of Revenue and the Department of Health and Family Welfare have to chalk out a road-map for cooperation which is likely to make morphine available, accessible and affordable to those who are in pain. The preamble to the United Nation's 1948 Universal Declaration of Human Rights states that "recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice, and peace in the world." To be able to live and die with dignity, free from pain, is a fundamental right of every human being, which we need to respect, nurture and ensure. It is time we recognize that freedom from pain is an inalienable right.
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